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Literature Review: PROMPT Therapy Craig Domanski PS 572--Teaching Language and Social Skills to Children with Autism Caldwell College.

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Presentation on theme: "Literature Review: PROMPT Therapy Craig Domanski PS 572--Teaching Language and Social Skills to Children with Autism Caldwell College."— Presentation transcript:

1 Literature Review: PROMPT Therapy Craig Domanski PS 572--Teaching Language and Social Skills to Children with Autism Caldwell College

2 Overview Article summary Search terms and parameters Critique –Guidelines for evidence-based practice References

3 Journal article summary Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT Interventions –Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006)

4 Introduction Children with autism have significant deficits in speech and language production –Language proficiency as an indicator for predicting outcomes Many interventions focus on language acquisition

5 Two approaches have been used historically: 1.“Discrete trial teaching” “Didactic, adult-directed instruction delivered from a pre-set curriculum often taught in massed trials” (Rogers et al., 2006) –After initial discrete trials, more complex language skills are taught through associative learning –Motivation is provided through external rewards

6 2.Naturalistic teaching methods (I.e., natural language teaching, incidental teaching, or pivotal response training) “Child-initiated behavior in a natural interactive context” (Rogers et al., 2006) Incorporates modeling, shaping, and “natural” reinforcers

7 Differences between DTT and naturalistic approaches Adult-directed v. child-directed Individualization of each learning opportunity Type of reinforcement Role of child as initiator Degree of generalization promotion

8 Both are behavioral approaches Language impairment for children with autism is a developmental disorder –Developmental interventions (Prizant) focus on: Social engagement Imitation skills Means-ends concepts Understanding language

9 The Denver Model A developmental approach to language acquisition –Specific developmental curriculum –Individualized –Based on discrete trials, naturalistic teaching methods, and dyadic exchanges Teaching based on attention to both teaching techniques and interpersonal relationships (Rogers et al., 2006) Can be implemented in inclusive classrooms, individual therapies, or 1:1

10 The Denver Model (cont.) Only 1 aspect of model implemented in current study (the communication curriculum) –Frequency: 1x/week, 50-min. session; daily home review by parents –Why?: typical of area programs –Description of session: naturalistic social-affective teaching interactions (“sensory social routines”) alternated with didactic instruction

11 Structure of sessions: –Highly motivating social games and activities Naturalistic teaching High frequency of social interactions –Imitation of actions (objects, body parts, oral-facial movements, speech sounds) Massed trials and naturalistic teaching –Receptive understanding (simple instructions) Naturalistic teaching –Object associations Matching (objects-pictures, pictures-objects) –Verbal approximations Naturalistic teaching Modeling, shaping, and reinforcement Put in a notebook with goals and objectives, lesson plans, and data

12 PROMPT Therapy PROMPT = Prompts for Restructuring Oral Muscular Phonetic Targets –Based on neuromotor principles of speech production (Chumpelik (Hayden), 1984) –Use of touch can: “Develop, rebalance, or re-establish speech motor control” “Provide a foundation for integrating sensory modalities in developing concepts and expressive language” “Enhance social-emotional interaction and trust between clinician and client” (Rogers et al., 2006)

13 Elements of PROMPT “Use of tactile-kinesthetic information as a critical modality for recognizing, developing, re-balancing, and integrating cognitive, linguistic, and motor behavior” “Determining a Communication Focus or an aspect of development in which to embed and focus communication intervention” “Developing goals and embedding objectives that embody the Communication Focus whil working on motor/language, cognitive, and social function”

14 Elements of PROMPT (cont.) “Analyzing the global and speech motor sub-systems to determine three priority areas that need immediate development or rebalancing and create an initial, functional lexicon (core vocabulary)” “Deciding on the purpose of prompting and what types of prompts should be used to support and develop motor control for speech and language and/or interaction and cognitive development” Concrete understanding of how chosen goals and objectives will directly affect motor resourcing and, therefore, materials, activity choices”

15 Elements of PROMPT (cont.) “Insuring that a high degree of motor-sound practice (using prompts for accuracy of production) and generalization of these into novel syllables and words within naturalistic activities are used within each session” “The inclusion of reciprocal interaction or choice- making, in all activities, in almost every turn.” “Presentation of the same or similar activities over time to provide a structure in which increased motor-language complexity and cognitive learning of events and sequences may be practiced.” (Rogers et al., 2006)

16 PROMPT in use Initially, use play-based activities, wait for child to initiate, and require a sound production –Then, use vocal modeling and manual manipulation (of jaw, lips, or other speech mechanisms) while child vocalizes –Fade tactile prompts to visual prompts (of hands moving)

17 The Denver Model v. PROMPT Similarities –Developmentally- based –Focus on shared attention and social interactions –Use naturalistic teaching methods –Match activities to developmental levels –Initially, adult- structured Differences –Organization of evaluation data –How goals and objectives are chosen –Organization of motor systems towards tasks –Use of imitation v. tactual-kinesthetic prompts –How tasks are taught –How programs are modified

18 Present study Purpose –Develop the methods and tests of both models for developing speech in non- verbal pre-schoolers with autism –Gather empirical support for both approaches –See if typical frequency of speech sessions with daily parent review would be sufficient in producing speech

19 Participants –10 children (aged 20-65 months) –Recruited through clinic specializing in treatment of ASD & parent-groups –Criteria for participation: Diagnosis of autism Spontaneous functional use of less than 5 words per day –From parent reports and clinical observations Developmental quotient of >30 No co-morbid conditions –NOTE: All participants received varying levels of outside therapies

20 Setting –2-room suite w/ one-way mirror –University of Colorado Autism and Developmental Disabilities Research Laboratory –All sessions videotaped

21 Design –ABA design (replicated 9 times) Pre- and post-treatment tests –Diagnostic, developmental, and speech-language assessments 10-min. speech samples in baseline, treatment, and maintenance phases

22 Procedure Pre-treatment assessments –Autism Diagnostic Observation Scale (ADOS) –Social Communication Questionnaire (SCQ) –Mullen Scales of Early Learning –Vineland Adaptive Behavior Scales –MacArthur Communicative Development Inventory (CDI) –Previous intervention history (through parent interview) Type of treatment, staff:student ratio, hours in therapy –Background information

23 Baseline –Baseline speech probes (x3) 15-min. Examiner put out a new toy every 5 min. and encouraged child to play with it –Play partner instructed not to initiate any activities –Made statements regarding child’s play Examiner asked for 1 request and 1 episode of joint attention Scored # of words and # of phrases emitted

24 Treatment Children randomly assigned to Denver Model or PROMPT –Received 1 hr./ week therapy (12 weeks) –Denver Model: parents present during session Taught to implement one new skill in each of 4 areas and had them practice –Asked to implement procedures for 45 min. per day

25 PROMPT –Parents observed sessions via video Parents asked to practice new words or approximations –Not required to manually prompt any responses Asked to implement procedures for 30 min. per day Family decided how to incorporate practice into daily routines

26 Procedure (cont.) Speech samples –Each session was videotaped; a 10-min. sample was randomly selected from each session Data collection –# of novel words or approximations –# of novel phrases –Function of communication (I.e., joint attention, social interaction) –Spontaneous v. prompted Summarized in graphs at end of the study

27 Post-treatment –3 weeks after completion –Same assessments as in pre-treatments Three month follow-up –Used to score child’s functional use of speech –Identical to speech probes in baseline

28 Treatment integrity –2 independent speech therapists trained up to fidelity on both interventions –Likert scales developed for both Developers of scales viewed videotapes regularly, visited quarterly, and supervised (by phone) monthly –Scored at 85% or better for 25% of sessions

29 Results




33 Results (cont.) 8 of 10 participants engaged in functional use of at least 5 novel words Generalization probes showed less use –Reasons? Not enough sessions (12) Sessions not targeted for generalization and maintenance Generalization sessions looked at too many novel features Children “not spontaneous enough”

34 Results (cont.) Overall gains –Significant gains = score of 2 or 3 on ADOS in pre-treatment, score of 0 on post-treatment –Significant gains observed in both interventions Denver Model: more in imitation skills PROMPT: more in functional play skills Generalization –9 of 10 participants used novel words at home after treatment Based on parent report

35 Most gains –One child in each group demonstrated very high levels of increases in target behaviors Regular use of over 50 words per session Increases in joint attention –Both exhibited milder forms of autism symptoms “These children may well have acquired functional speech without these treatments.” (Rogers et al., 2006) NOTE: 2 participants did not acquire any new words

36 Discussion Purpose was preliminary tests of interventions –Experimenters urge more research More replication and extensions 8 participants generated some new speech, 4 generated novel phrases, 2 used phrases in generalized manners (novel statements in novel settings) Positive parent feedback

37 Limitations Children already in a developmental period where language is observed to accelerate Gains observed were still considered limited compared to typical children Better gains observed for participants with higher levels of parent involvement –Parents provided extra practice opportunities than what was specified Implementation monitored by parent report

38 Limitations (cont.) Direct comparison of 2 interventions was impossible –Too many similarities Participants differed from one another (age, mental ages, expressive language capabilities) Many components to each treatment Limited generalization and maintenance data Children were receiving outside therapies concurrently No IOA

39 Future research Obtain similar participants –Control for effects of treatment Component analysis of each treatment Control for more extraneous variables –I.e., outside therapies

40 Search parameters JABA PsycINFO Google First, attempted “PROMPT Therapy” –0 in JABA; mixed results in PsycINFO, 8060 on Google Link for –Tab for research; provides a research summary –No articles mentioned were peer-reviewed Out of 6 articles mentioned… –2 unpublished research, 2 conference proceedings, 2 manuals authored by Hayden –Other links to “research” were all presentations given by Hayden or colleagues –1 study available (Rogers et al.)

41 PROMPT: Introduction to Technique: A Manual (2006) –References section Chumpelik--3 articles (2 unpublished, 1 theoretical) Hayden--11 articles (0 research studies) –Guides, manuals, assessments, etc.

42 Rogers et al. study (Hayden co- authors) –References section Looked at all research containing PROMPT –5 references (all Chumpelik or Hayden) –All unpublished, theoretical, or conference proceedings Google search for entire titles of all possible research studies –None available

43 ASAT online –“Research Summary: One small study indicates that an oral-motor therapy, PROMPT, may be efficacious in establishing early language skills in nonverbal children with autism (Rogers et al., 2006). There have been no other peer-reviewed scientific studies on Oral-Motor Training or Therapy for individuals with autism spectrum disorders.” (2008) –“Recommendations: Researchers may wish to conduct studies with strong scientific designs to evaluate Oral-Motor Therapies. Professionals should present Oral-Motor Therapies as under-researched and encourage families who are considering these interventions to evaluate them carefully.” (2008)

44 Does PROMPT have enough evidence to support its use? Gina Green’s “gold standards” for evidence based practice… –At least 3 between group designs demonstrating efficacy…NO –At least 3 single case designs demonstrating efficacy…NO –At least 3 investigators needed for corroboration…NO –Documentation of: How participants were obtained…YES Continuous measurement of DV…NO Calibrated data collection…NO Inter-observer agreement…NO Procedural integrity…YES (25% of sessions) Operationally defined baseline condition…YES Treatment effects…NO

45 Conclusions?

46 References Rogers, S., Hayden, D., Hepburn, S., Charlifue-Smith, R., Hall, T., & Hayes, A. (2006). Teaching young nonverbal children with autism useful speech: A pilot study of the Denver Model and PROMPT interventions. Journal of Autism and Developmental Disorders, 36, 1007-1024. Hayden, D. (2006). PROMPT: Introduction to Technique: A Manual. Santa Fe, NM: The Prompt Institute. Association for Science in Autism Treatment (2008). Retrieved June 11, 2008, from The Prompt Institute (2008). Retrieved June 11, 2008 from Green, G. (2008). Evaluating Evidence about Treatments for Autism. Presentation for Applied Behavior Analysis International Conference, San Diego, CA.

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